14 forefoot inuries n athletes - university of texas

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Forefoot Injuries in Athletes

Mark M. Casillas, M.D.

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Disclosure

• No relevant disclosures to report.

Forefoot Injuries in Athletes

• Sprains

– 1st MTP

– Lesser MTP

• Fractures

– Mid to Distal MT fractures

– Toe fractures

• Nail Bed Injuries

1st MTPJ

An important component of the healthy lower extremity


Biomechanics

1st MTPJ joint is designed for the transmission of tremendous power to the great toe and multiples of body weight through the foot.

Turf Toe

• Sprain of the plantar capsuloligamentouscomplex

• The profound athletic disability poignantly illustrates the great toe’s relevance to the lower extremity

Mechanism of Injury

• Hyper‐dorsiflexion

• Also:

– Varus

– Valgus

– Plantarflexion

Bowers and Martin, 1976

• Forced dorsiflexion mechanism of injury in football players

• Related to the use of flexible soccer style shoes on hard artificial turf (1st Gen)

• Established “shoe‐surface relationship”


History

• Axial load

• Dorsiflexion 1st MTP

Physical Exam

• Circumferential swelling• Bruising• Tenderness centered on the first MTPJ

• Passive extension is painful and guarded

• Resisted plantar flexion may be weak

• Instability may be present

Imaging‐ Radiographs

• STS at the 1st MTPJ

• Subtle avulsion fx

– Base of the P1

– MT head

• Compression fx dorsal aspect of the MT head

• Overt fx sesamoid(s)

• Sesamoid proximal migration

Imaging‐MR

• Dedicated extremity coil

• 3 Tesla magnet if available

• Plantar plate edema with partial or complete rupture

• Sesamoid edema or fracture

• Dorsal impaction fracture at the MT head


Clanton Classification Initial Treatment

• RICE

• Non‐weight bearing pending formal evaluation

• Subsequent treatment is dictated by the grade of injury

Grade 1

• Weight bearing as tolerated

• Post‐op shoe or stiff shoe supplemented by a carbon fiber plate

Grade 1‐ Patient education

• Stiff‐sole shoe

• Carbon fiber plate

• Taping program to resist DF at 1st MTPJ



• Stiff sole shoe




• Stiff sole shoe



Grade 2

• Non‐weight bearing (3‐7 days)

• Splint

• Cold therapy

• Cast boot

– Weight bearing to tolerance


• Stiff‐sole shoe




Grade 3‐Non‐Surgical Treatment

• Non‐weight bearing for up to 8 weeks

• Physical therapy

– Active ROM

– Coordinated activity

• Towel scrunches

• Toe pick‐ups


• Physical therapy

– Joint mobilization


• Return to sport phase

– 3 to 12 weeks after injury

– Plyometrics

– Sport‐specific drills

– Appropriate shoe wear and taping

Grade 3‐ Surgical Treatment

• Infrequent

• Unstable joint

• Intra‐articular loose bodies

• Retracted sesamoids

• Traumatic bunion



• Medial approach

– Extensile

– Plantar to the midline

• Plantar approach

– Extensile

– “L”

• Remove loose bodies


Surgical Treatment

• Plantar plate repair

– 2‐0 braided, non‐absorbable sutures

– Suture anchors base of the P1

– Repair or partial excision sesamoid fractures

– Repair of MCL

Turf Toe Complications

• Intrinsic minus toe‐ cock‐up

• Loss of push‐off power

• Stiffness

• Pain

• Hallux valgus

• Hallux rigidus

• Osteoarthritis

• Transfer lesions


Hallux Rigidus Lesser MTP Sprains

• Uncommon

• Barefoot and sandals

Lesser MTP Sprains

• Classification

– Low grade

– Hi grade

• No dislocation

• Dislocated– Reducible

– Irreducible

Treatment for Stable Joints

• RICE

• Cast boot or stiff shoe

• Return to sport

– protective shoe

– inserts

– taping


Treatment for Dislocated Toes

• Reduce dislocated joints as soon as possible– Local or general– Closed reduction– Open reduction and repair

– Once reduced and stable• Cast boot or stiff shoe

– Return to sport• protective shoe• inserts• taping

Lesser Toe Sprain Complications

• Chronic dislocation

– Painful

– Hard to fit in shoe

– Progressive arthritis

• Deformity

• Stiffness

• Osteoarthritis

Mid to Distal MT Fractures

• 1

– Relatively stable

– Significant weight transfer

• 2 and 3

– Longer

– Most stable

– Least forgiving


• 4 and 5

– Vulnerable to twisting

– Least stable

– Most forgiving



• Intra‐articular fractures

– Need near perfect articular alignment

– May lead to pain, deformity, stiffness, and OA

Treatment

• Non‐surgical treatment

– Adequate alignment

– Perfect joint alignment

• Surgical treatment

– Mal‐alignment

– Articular incongruity

Non‐Surgical Treatment

• Cast

• Cast boot

• Non‐weight bearing or WBTT

• Functional foot and ankle rehab

Surgical Treatment

• ORIF

– Adequate bone

– Minimal comminution

– Aim for perfect alignment and congruity


Surgical Treatment

• Open reduction and k‐wire fixation

– Inadequate bone stock

– Severe comminution

Distal MT Fracture Complications

• Delayed union

• Non‐union

• Malunion

– Metatarsalgia

– Transfer lesions

Distal MT Complications5th MT Malunion with Toe Abduction

Toe Fractures

• Great toe

– Majority of weight transfer

– Least forgiving

• 2, 3, 4 toes

– Relatively protected

• 5 toe

– Unprotected

– Very forgiving


Treatment

• Non‐surgical treatment

– Adequate alignment

– Perfect joint alignment at MTP and Great Toe IP

• Surgical treatment

– Mal‐alignment

– Articular incongruity at MTP and Great Toe IP

– Nail Bed Lacerations (Open Fractures)

Non‐Surgical Treatment

• Nail management

• Cast

• Cast boot

• Non‐weight bearing or WBTT

• Functional toe and foot rehab

3rd Toe Distal Phalanx Fracture


Surgical Treatment

• ORIF

– Adequate bone

– Minimal comminution

– Aim for perfect alignment and congruity

Surgical Treatment

• Open reduction and k‐wire fixation

– Inadequate bone stock

– Severe comminution

5th Toe Fracture Dislocation 5th Toe Fracture Dislocation


5th Toe Fracture DislocationNail Bed Laceration

13 yo, soccer player, hyper‐PF

Nail Bed Repair

• Remove Nail Plate

• Debride fracture

• Reduce Fracture

• Fracture Fixation

• Nail bed repair

– Fine chromic suture

51 year old, weight fell on toe


71 year old, car jack injury Toe Fracture Complications

• Nail deformities

• Pain

• Stiffness

• Arthritis

• Malunion

Don’t be fooled Subungual Malignant Melanoma

• Deadly

• No history for trauma

• Non‐clearing discoloration

• Band of pigment

• Distal skin pigmented


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Thank You!

Mark M. Casillas, M.D. –Orthopaedic Surgery, Foot & Ankle

Jeremy L. Dickerson, M.D. – Family Practice, Sports Medicine

Stacé S. Rust, M.D. –Orthopaedic Surgery, Hand, Wrist, Elbow & Shoulder

Ryane M. Cordero – MPAS, PA‐C

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14 forefoot inuries n athletes - university of texas

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